The face is arguably one of the most important features of the human body. It provides to others the first clues to one’s identity and personality. It contains the features, such as the eyes, ears, and mouth, that allow us to communicate and interact with one another. And it offers the first visual cues that determine whether other people perceive us as male or female. For these reasons, facial feminization surgery (FFS) is a fundamental aspect of the male-to-female transition. In fact, the World Professional Organization for Transgender Health (WPATH) regards FFS as both medically necessary and essential to the well-being of transgender individuals. In a 2008 report, WPATH stated “these surgical interventions are often of greater practical significance in the patient’s daily life than reconstruction of the genitals”.
The term “facial feminization surgery” refers to a number of procedures that can be performed to give the face a softer, more traditionally feminine appearance. These can include both bony and soft tissue surgeries of the face, neck, and thyroid cartilage, often complimented by laser hair removal. While each patient will have unique needs, typical FFS procedures include brow lift with bossing, scalp advancement, nose reshaping, blepharoplasty, tracheal shave, cheek implants, lip lift, lip and cheek implants, cheek softening, and face/neck lift. Combined, these procedures can offer the transwoman a greater degree of harmony between her inside and outside self, increase her self-esteem, and allow her to “pass” more effectively.
There is no one feature that defines a “feminine” or “masculine” face. Rather, the degree of femininity expressed in a human face is typically the result of the combination of multiple facial features, and the ratio of feminine to masculine features. Facial features traditionally considered masculine include brow bone bossing, a prominent nose and chin, thick eyebrows, a square jaw, a long face, and a visible Adam’s apple. In short, men tend to have chiseled, more angular features. In contrast, women usually possess softer, rounder facial characteristics—a smooth forehead without bossing, a pointed chin, a more delicate nose, fuller cheeks, and an arched brow. Generally, facial feminization is achieved through bone reduction and changes to the skeletal framework.
Because every patient is unique, the surgeons at the International Center for Transgender Care don’t believe in a “one-size-fits-all” approach. Instead, we opt to work with each patient to design a unique treatment plan tailored to your individual needs. Our surgeons are not only highly skilled technically, but have the aesthetic and artistic awareness to know what constitutes a feminine face. During a consultation appointment, your surgeon will meet with you to assess your facial structure, discuss your needs, and answer any questions you have about FFS and the recovery process. Most transwomen elect to have all facial feminization procedures performed at once, or in two phases (upper face and lower face). If performed all at once, FFS usually takes between 6-12 hours. In general, patients who undergo FFS will stay overnight after their procedure and return home the following day. Some swelling and discomfort is expected, but this typically resides after about 7 days, with full recovery expected within 3-4 weeks.
Brow Lift with Bossing
The male and female eyebrows and forehead differ significantly. Males often have a ridge of bone surrounding their upper eye sockets—this is known as bossing. Additionally, men tend to have a more steeply sloping forehead and eyebrows that are straight and positioned lower on the face. In contrast, the female face tends to be flatter in profile, with no bossing and eyebrows that are higher and more arched in appearance. FFS that focuses on the eyebrow and forehead regions tends to be very effective in feminizing the overall appearance of the face. During this procedure, bossing can be shaved down, the brow can be lifted, and the overall shape of the forehead can be re-contoured. Some pain is to be expected following this procedure, and patients may experience temporary numbness of the forehead.
The hairline also differs across gender. Males typically have a higher, M-shaped hairline, while females tend to have a lower hairline that is shaped like an inverted U. Scalp advancement can be used to feminize the face. During this procedure, a fine incision is made from temple to temple, and the scalp is lowered to achieve a feminine hairline and the illusion of a shorter face. Sutures and a bandage will be left in place for about one week following the surgery.
Nose Reshaping (Rhinoplasty)
While masculine noses are typically prominent with a bulbous tip, feminine noses are smaller and delicately curved, with a more defined tip. The angle between the forehead and nose is usually more vertical in females, while the angle between nose and upper lip is more accentuated. The goal of rhinoplasty within FFS is the creation of a feminine nose that matches the patient’s overall facial proportions. This is one of the most common and effective feminizing procedures available for the face. After rhinoplasty, a cast will be placed on the nose for about one week, along with absorbable sutures to close the surgical incisions. Some bleeding, bruising, and pain is expected. Definitive results of the procedure will be visible after about six months.
This procedure is often performed along with FFS to correct the aging process and lend a more youthful, beautiful look to the face. Blepharoplasty is used to remove eye bags and excess folds of skin from the corners of the eyes. Initial swelling and bruising is expected, but should subside within two weeks.
A tracheal shave is performed to eliminate the visible “Adam’s apple,” a defining feature of the male visage. The Adam’s apple is actually a projection of the cartilage that makes up the voice box. During a thyroid cartilage reduction, or tracheal shave, the Adam’s apple is reduced to create a more feminine appearance. While this is a quick procedure, it should be performed by an expert surgeon as shaving the trachea too aggressively could result in permanent damage to the vocal cords. Tracheal shave is typically combined with other FFS procedures, although it can also be performed separately under local anesthesia. Following tracheal shave, patients should expect some temporary pain, swelling, and vocal weakness.
Feminine faces often have cheeks that are rounder and more prominent than those found on men. During FFS, cheek augmentation can be performed to mimic this fuller, more feminine look. In this procedure, small silicone implants are placed in the cheeks. These implants are available in a variety of shapes and sizes to best suit the needs of each patient. An incision is made inside the mouth, which prevents visible scarring on the face, and a pocket is created under the cheek to hold the implant. This procedure can usually be completed within one hour. Some swelling and pain is to be expected following cheek augmentation. Additionally, sutures will be placed—these should dissolve on their own in about two weeks.
A youthful, feminine face will have a short upper lip with good projection, less space between the top of the lips and the bottom of the nose, and good visibility of the teeth. During a lip lift, a small incision is made at the base of the nose and the lip area is lifted to expose the teeth and achieve more feminine proportions for the lower face. Patients who have undergone a lip lift will have dissolvable sutures placed. It is also common to experience some swelling and tightness around the mouth area for several weeks following this surgery.
Patients who desire additional fullness to complement a lip lift may opt for lip implants. These are silicone implants that can be inserted into the lips through in a small incision in the corner of the mouth. Lip implants allow for a fuller, more feminine look. Pain and recovery time with this procedure are minimal, with some swelling expected for about a week following the augmentation.
Male and female chins tend to differ greatly. The typical masculine jaw is full and chiseled, with a square shape and a higher position relative to the rest of the face. In contrast, female chins tend to be lower and less square-shaped. Chin softening is offered to provide a softer, more tapered lower face with a feminine, defined facial profile. During chin augmentation, which is also referred to as genioplasty, both the height and width can be reduced. Metal plates and screws are then placed to permanently hold the chin in the desired position, and chin implants can also be used. As with other FFS, some swelling and pain is to be expected following the procedure.
As we age, the skin tends to sag and lose its youthful contour. Because mature skin has less natural elasticity, it may not be able to rebound fully from the stretching that occurs during FFS. For this reason, older transwomen may require a face lift to fully experience the benefits of their other FFS procedures. In addition, face lift and neck lift procedures can be used generally to tighten aging, sagging skin, for a more youthful appearance. Face and neck lift patients will have stitches and plastic tubes placed under the skin. Post-surgery side effects include pain, swelling, and bleeding.
Facial feminization surgery is a vital component of the male-to-female transition, offering many physical and psychological benefits for the transwoman. Because FFS is such an important procedure, it is paramount to work with only the most expert surgeons. At the International Center for Transgender Care, our board-certified surgeons have more than 20 years of experience treating transgender patients. We are proud to offer all of our services in a respectful, welcoming environment at our world-class surgical center in Dallas, Texas. We look forward to assisting you in achieving the very best possible results for your FFS. Contact us today to schedule a consultation at (972) 543-2477.